Barriers and facilitators to Water, Sanitation and Hygiene (WaSH) practices in Southern Africa: A scoping review

A healthy and a dignified life experience requires adequate water, sanitation, and hygiene (WaSH) coverage. However, inadequate WaSH resources remain a significant public health challenge in many communities in Southern Africa. A systematic search of peer-reviewed journal articles from 2010 –May 2022 was undertaken on Medline, PubMed, EbscoHost and Google Scholar from 2010 to May 2022 was searched using combinations of predefined search terms with Boolean operators. Eighteen peer-reviewed articles from Southern Africa satisfied the inclusion criteria for this review. The general themes that emerged for both barriers and facilitators included geographical inequalities, climate change, investment in WaSH resources, low levels of knowledge on water borne-diseases and ineffective local community engagement. Key facilitators to improved WaSH practices included improved WaSH infrastructure, effective local community engagement, increased latrine ownership by individual households and the development of social capital. Water and sanitation are critical to ensuring a healthy lifestyle. However, many people and communities in Southern Africa still lack access to safe water and improved sanitation facilities. Rural areas are the most affected by barriers to improved WaSH facilities due to lack of WaSH infrastructure compared to urban settings. Our review has shown that, the current WaSH conditions in Southern Africa do not equate to the improved WaSH standards described in SDG 6 on ensuring access to water and sanitation for all. Key barriers to improved WaSH practices identified include rurality, climate change, low investments in WaSH infrastructure, inadequate knowledge on water-borne illnesses and lack of community engagement.


Introduction
Inadequate water, access to improved sanitation, and hygiene (WaSH) are global health challenges affecting about one-third of the world's population [1,2]. Improved sanitation and hygiene are essential because they reduce environmental health risks [3]. Global  disease statistics show that more than one million annual deaths are related to poor WaSH practices as over one-third of the world's population do not have basic sanitation [4]. Although adequate WaSH coverage is critical for improving quality of life, globally about 2 billion people do not have access to clean water [5] and over 263 million people walk long distances to collect water from rivers, streams and lakes. Furthermore, at least 159 million people drink water from unsafe sources [5].
In Africa, about 70 percent of rural water schemes are non-functional or intermittently functional at any given time [6] resulting in compromised human wellbeing [7]. Due to poor WaSH practices in Africa, about 28 percent of the population in the region still practice open defecation [1]. Unsafe sanitation behaviours are responsible for around 775, 000 world deaths annually of which 5 percent are in low-income countries [1]. Universal, affordable, and sustainable access to WaSH is one of the key public health and developmental issues. Plans to improve WaSH coverage are instituted in the Sustainable Development Goals (SDG) goal 6 which seeks to ensure availability and sustainable management of water and sanitation for all by 2030 [8]. Even though this SDG advocates for progressive reduction of inequalities related to hygiene and universal access to clean water and sanitation [8], continued inequalities in access to clean water and improved sanitation between rural and urban settings are still a challenge [8][9][10][11].
Improved WaSH practices have the potential to reduce the prevalence of diseases such as schistosomiasis, cholera, diarrhea, polio, and typhoid which are prevalent in most sub-Saharan African countries. However, people still lack adequate information on WaSH leading to poor sanitation and hygiene practices. Southern Africa is among regions with very low rates of WaSH coverage in the world [8]. The provision of clean water to most rural communities in Southern Africa is insufficient and this exacerbates challenges associated with sanitation and hygiene [12]. For instance, hand washing is a cost-effective and simple approach used for the control of water-based infections and yet despite its simplicity and effectiveness it is not widely used [13].
Mitigating inequalities linked with access to WaSH is therefore critical. Understanding patterns of inequalities in WaSH practices, and how these are influenced by different facilitators and barriers is vital to providing effective interventions to mitigate inequalities in WaSH coverage in Southern Africa. Using a scoping review guided by the methodological framework for scoping, we examined facilitators and barriers to effective WaSH practices in Southern Africa and identified knowledge gaps on the same [14].

Design
We conducted a scoping review of published peer-reviewed articles on barriers and facilitators to WaSH practices in Southern Africa. The use of scoping review studies allows researchers to identify and analyze existing evidence from published peer-reviewed journal articles related to specific research areas. Scoping reviews are conducted to understand the status of knowledge related to a topic of interest [14]. Our review included studies published from 2010 to May 2022 and was guided by Arksey and O'Malley's 2005 scoping review framework which describes six stages: (1) identifying the research question; (2) identifying relevant studies; (3) selecting studies; (4) recording data; (5) organizing, summarising and reporting the results and (6) consultation exercise [14]. The optional six step is usually conducted with key stakeholders to inform and validate study results [14]. We did not include that in our review.

Search strategy
Our review focused on peer-reviewed journal articles, both quantitative and qualitative studies published from 2010 to May 2022 to identify facilitators and barriers to WaSH practices. We conducted a systematic electronic search of peer-reviewed journal articles from various databases including PubMed, EbscoHost, Medline and Google scholar using the following keywords: "facilitators; barriers; water; sanitation; hygiene; WaSH practices and Southern Africa." Using the keywords, we developed "index terms" by combining keywords and their synonyms and used the Boolean operators "AND", "OR" and truncations to create search strings: "Water AND sanitation AND hygiene AND Facilitators (AND motivators) AND barriers (OR hindrances) AND WASH practices AND Southern Africa". After eliminating all the duplicates for extracted articles, we identified relevant articles by screening the titles and abstracts. Full articles of the selected titles and abstracts were selected for eligibility. These articles were further screened (full-text) for relevance in terms of their focus and aims.

Inclusion and exclusion criteria
The review included articles describing interventions on WaSH practices in Southern Africa with a particular focus on facilitators and barriers. Articles included in the study were published in the English language from 2010 to May 2022. We excluded reviews, i.e. systematic, scoping and meta-analysis that were published before 2010. Our review also excluded reports, working papers and articles published before 2010. Our exclusion criteria further excluded articles that were published in other languages other than English.

Quality assessment
We assessed all selected articles for quality using a mixed methods appraisal tool (MMAT) [15]. MMAT is used as a tool to appraise the quality of different study designs [15]. For each study, we used scores ranging from 0 to 10, where 0-4 = "Low" quality, 5-7 = "Moderate" quality and 8-10 = "High" quality. The majority of the articles selected scored moderate. No studies scored "Low", 17 articles scored "Moderately" and one article scored "High". Indicators used for quality scores included: (a) a clear definition of the study objective and aim, (b) study design appropriate for stated aims, (c) justified sample size, (d) targeted population defined, (e) risk factor and outcome variables measured, (f) methods clearly described, (g) study results described, (h) discussions and conclusions justified, (i) study limitations discussed and (j) ethical approval for the study attained.

Data extraction and analysis
In the data extraction phase, a total of 18 articles were selected (Fig 1) based on the inclusion and exclusion criteria. All records were downloaded using Zotero software and duplicates were removed. We created a data extraction table (Table 1) that captured the following information: authors, year of publication, objectives of the study, the type of the study, geographical location from where the studies were conducted and the summary of the main findings from each study.

Results
Our electronic search from PubMed provided 1252 records, EbscoHost 62 records and 75 records from Google scholar. The electronic title search provided a total of 1389 articles (Fig 1) from which 24 duplicates were removed. One thousand, three hundred and one (1301) articles were deemed illegible and were removed after screening their titles. Sixty-four (64) articles that remained were screened based on their relevance by abstracts and of these, twenty-one (21) articles were removed. Full-text screening for the remaining 43 articles was done and 30 articles were removed due to irrelevant focus and aim concerning the objective of this review. Among those removed, one article covered a scope outside Southern Africa, another article used secondary data collected between 1995-2006 although the paper was published in 2015. One article was a working paper, and the other excluded studies were reports, systematic and scoping reviews. We remained with 13 legible records deemed relevant. Five (5) additional records were identified from the reference lists of eligible articles and were included as grey literature for full-text review resulting in a total of 18 articles (Fig 1).
Barriers to WaSH practices. The key themes that emerged with regards to barriers to WaSH practices in Southern Africa from the articles reviewed comprised (a) inadequate financing, (b) population growth, (c) inadequate knowledge of waterborne diseases, (d) ineffective local community engagement in WaSH interventions, and (d) climate change.
Inadequate financing. Lack of skilled personnel and poor laboratory equipment was reported to compromise the quality of water and water supply services owing to insufficient funds [19]. The situation compromises clean water supply, and resulting in poor sanitation and hygiene practices [19,22]. Due to insufficient funding, in some places where there was WaSH infrastructure in place, there was poor or no maintenance on the damaged infrastructure. The challenge of broken WaSH infrastructure contributes negatively to improved sanitation and hygiene practices. Inadequate funding led to inadequate WaSH infrastructure  Gwimbi, P. (2011) [28].
The microbial quality of drinking water in Manonyane community: Maseru District (Lesotho).
To assess, at micro level the E. coli and total coliform counts in water samples from different drinking water sources in Manonyane community. A household analysis was conducted to assess the community's perception towards the quality of its water and practices aimed at protecting its sources. The study was planned to provide information that could assist in working out a model for safe drinking water supply to the community.

Cross sectional study
Lesotho Prompt intervention to mitigate the potential health impact of waterborne diseases in the community. A proper sanitary survey and implementation of water and sanitation projects in the community.
Pollution. Poor source water protection. Poor sanitation and low level of hygiene practices. Lack of monitoring and healthcare awareness.
(Continued ) The current study was carried out to evaluate the microbial quality of wells and boreholes in Stink water, a peri-urban community of South Africa, using E. coli as an indicator organism. More importantly, the study also sought to determine the prevalence of pathogenic E. coli virulence-associated genes in these water sources so as to infer any possibility of infection from the consumption of untreated water from these water sources.
South Africa Pathogenic E. coli strains.
(Continued ) Effect of a behaviour change intervention on the quality of peri-urban sanitation in Lusaka, Zambia: a randomised controlled trial.
To investigate to what extent sanitation could be improved by the residents of an informal settlement in Zambia themselves, through behaviour change promotion alone, in the absence of institutional change or financial subsidy.

Mixed methods Zambia
The poor quality of toilet provision. Willingness to pay for quality improvements of toilets.
Toilets shared by multiple households.
(Continued ) especially in rural areas [27,31]. Water quality and supply from many countries was reported to be compromised due to a lack of WaSH infrastructure. Some studies reported poor and inadequate protection of water sources, poor access to clean water and dependency on contaminated water from unprotected sources [30]. There were reports of water sources contamination by human excreta because of a shortage of latrines, or lack thereof. Inadequate investment in WaSH infrastructure was reflected by poor maintenance of the existing infrastructure. Geographical inequalities were identified as an existing barrier to improved drinking water supply, sanitation and hygiene particularly in rural areas of Southern Africa. Population growth. It was evident that there was strain on WaSH services predominantly in urban areas where demands for WaSH services increased due to rapid population growth [25,30]. For example, the challenge with population growth in some countries as evidenced by the inability to efficiently provide clean water services for the growing informal settlement population. In some instances, rapid population growth led to congestion thereby compromising sanitation and hygiene practices especially in places where sanitation facilities were shared. Overcrowded spaces in some countries were reported in different studies as a major factor contributing to pollution and poor neighbourhood sanitation and hygiene practices. From the studies reviewed, concerns about space/land emerged especially with regards to replacing pit latrines that filled up quickly owing to population growth.
Inadequate knowledge on healthy WaSH practices. People's perceptions, knowledge and reported behaviors regarding WaSH facilities such as latrines reflect their knowledge of healthy WaSH practices. Due to inadequate knowledge on the importance of improved sanitation and hygiene, some people are reluctant to change their behavior and learn how to use the introduced latrine facilities [29][30][31]. This was seen in places where community members practiced open defecation. Some community members were reluctant to accept and use latrines. Inadequate knowledge on the transmission of diseases associated with poor WaSH practices was reported as one of the challenges to healthy lifestyle change.

PLOS ONE
Ineffective local community engagement. Effective local community engagement in interventions for WaSH practices is critical. From the studies reviewed, there is evidence that ineffective local community engagement in interventions results in a lack of monitoring and healthcare awareness [26,27]. Engaging local community members from the design of interventions to their implementation is crucial. Some studies reviewed alluded to successful community-led total sanitation implementation resulting from effective local community engagement.
Climate change. Climate change exacerbates public health issues associated with poor sanitation and hygiene practices. The findings from some of the reviewed studies reported drought as one of the influencers to barriers to improved WaSH practices. Inadequate water supply, especially during the dry seasons was described as a constraint to improved hygiene including handwashing [33]. Different countries in Southern Africa experience droughts due to climate change and that compromises WaSH practices. Among other challenges, drought seasons experienced in Southern Africa contribute to the existing challenge of disease control in endemic regions where improved WaSH facilities are most needed [25,26]. The following themes emerged as key facilitators to WaSH practices in the region, (a) effective local community engagement, (b) increased investment on WaSH infrastructure, (c) increased latrine/toilet ownership by individual households and (d) development of social capital within small community units.
Local community engagement. The reviewed studies indicated the importance of the local community's engagement in WaSH related interventions that promote improved sanitation and hygiene practices in society [16,26,29]. Initiatives such as community-led sanitation and hygiene were easily introduced in places where the local community members were effectively engaged [17,27]. In places where communities used community latrines, communityled sanitation programs led to easy decision-making processes because local communities were practically engaged in interventions [21].
Investment in WaSH infrastructure. WaSH infrastructure is critical for improved WaSH services. Some of the studies reviewed, from South Africa reported the benefits gained from increased investment in WaSH infrastructure [31]. Such benefits include improved access to sanitation and hygiene facilities. Investments on WaSH infrastructure also improved safewater-storage minimizing contamination [30].
Toilet ownership. The studies reviewed showed that latrine ownership by individual households played an important role in practicing healthy WaSH behaviors. Increases in individual households' ownership of a latrine reduces open defecation practice, and the use of shared latrines and promotes a healthy lifestyle [21]. The reviewed studies indicated informal settlements as some of the places at which community members struggle to maintain improved sanitation and hygiene [21,22].
Social capital development. The importance for any society to have established networks of relationships was evident in the reviewed articles. Such social capital networks contribute positively towards improved WaSH facilities and positive attitudes and behaviors [21]. The studies reviewed indicated that the development of social capital was easily established in small communities leading to effective communication essential to creating healthy living awareness in these settings.

Discussion
Our review of published articles on WaSH practices in Southern Africa identified and analyzed facilitators and barriers to the effective implementation of WaSH. The following barrier themes emerged from the analysis: (1) geographical inequalities, (2) climate change, (3) low investment in WaSH infrastructure, (4) low knowledge levels on waterborne diseases, (5) ineffective local community engagement. Facilitators for WaSH practices that emerged from the analysis included: (a) effective local community's engagement in WaSH interventions, (b) increased investment on WaSH infrastructure, (c) local community's engagement in WaSH interventions, (d) increased latrine ownership and (e) development of social capital within small community units.

Geographical inequalities
While notable advances have been made in the provision of drinking water supply and sanitation worldwide [34], poor sanitation and inadequate clean drinking water supply especially in rural areas remain an important challenge in most African countries [22]. The existing barriers to improved drinking water supply and sanitation are the geographical inequalities experienced in most rural areas in Southern Africa where there are generally poor basic services provision resulting in unhealthy living conditions [29].

Climate change
Climate change was noted as a significant challenge to water and sanitation services posing risks like damage to infrastructure due, for example, to flooding, depletion of water sources due to declining rainfall and increasing demand; and compromised water quality [35]. We noted that climate change has affected both surface and groundwater flow. Understanding the interaction between climate change, land usage, the demographic and economic activities in the region is essential in ensuring that there is water security in Southern Africa [25].

Low investment in WaSH infrastructure
The results of the review showed that Southern Africa is among the regions with the lowest basic sanitation coverage of homes that have access to clean and safe drinking water. Poverty [19], and sharing of sanitation facilities were noted as contributing factors to poor WaSH practices in Southern Africa [21]. Insufficient investment on sanitation and hygiene resources [32] in Southern Africa contributes tremendously as a hindrance to improved WaSH practices. Addressing this requires a political will of governments to increase investments targeted to improve WaSH infrastructure. The current low investment in WaSH resources in most of the Southern African countries has led to poor implementation of water safety plans [19,26]. Due to low investment in WaSH infrastructure, compliance of small water treatment plants to accepted standards of drinking water quality and management has resulted in inadequate provision of water supply and sanitation facilities especially in rural areas remains a challenge [19]. Rapid urbanization has added to the strain on investments that could be used to improve sanitation infrastructure in Southern Africa. We have noted that urbanization has concentrated people in areas but not matched that with sanitation development This has led to failure to meet the growing urban population's improved WaSH needs [25].

Low knowledge levels on water borne diseases
An increase in knowledge related to water-borne diseases may contribute to a decrease in the prevalence of water-borne diseases. However, low levels of knowledge on water-borne diseases and their transmission routes have been reported in Southern Africa [31]. This may be improved through health education on the role of WaSH practices in reducing water-borne diseases [26,36].

Effective local community's engagement in WaSH interventions
This review indicated that effective community engagement plays a critical role in ensuring that interventions succeed [37]. Implementation challenges comprising cultural practices, possible negative attitudes and poor communication during the intervention can be eliminated through effective local community engagement. In addition to overcoming several implementation challenges, effective community engagement encourages positive attitudes in community-led intervention programs [17,27,32].
The major facilitators to WaSH practices in this review were: (1) increased investment on WaSH infrastructure, (2) effective local community engagement, (3) increased latrine/toilet ownership by individual households, and (4) development of social capital within small community units.

Increased investment in WaSH infrastructure
Increased investment in WaSH infrastructure was identified as an important facilitator to improved WaSH practices [26]. Although the SDGs for safe drinking water have been achieved globally [18], many people, in rural Africa are still dependent on unsafe water sources such as rivers and unprotected wells for domestic use. Through increased investments in WaSH infrastructure, some countries in Southern Africa have improved access and availability of clean water [26] and stepped up effective promotion of hygiene practices [16], improved knowledge, attitudes and practices towards hygiene and sanitation [26]. Another benefit of increased investment for WaSH infrastructure is the improvement of water source protection [27] which is a major challenge in most Southern African communities. Furthermore, improved infrastructure can contribute toward better water storage at home [20].

Local community's engagement in WaSH interventions
Our study findings indicated effective local community engagement in WaSH interventions as one of the important facilitators to WaSH practices [32]. Effective engagement of local communities in interventions stimulates interest in interventions and results in increased levels of knowledge on water-borne diseases [26]. Through effective engagement, community-led sanitation and hygiene education programs are easily introduced and executed [17]. Furthermore, engaging the local community assists in mobilizing the adaptation of new sanitation technologies such as ecological sanitation (ecosan) [29], a technique that makes it possible to safely use human excreta in agriculture [29]. In cases where the community uses shared latrines, effective community engagement makes promotes collective decision-making among shared larine users easier [21].

Increased latrine ownership
Open defecation is mainly a rural phenomenon ascribed to poor latrine ownership at the community and household levels [38]. The results from the review showed that increased latrine ownership by individual households contributes to improved WaSH practices in a community [21]. Lack of sanitation facilities leads to uncontrolled disposal of household and human waste into surrounding water bodies leading to pollution and an increased risk for water-borne infections in society [18].

Development of social capital within small community units
Developing social capital was identified as an effective strategy for health improvements especially in small communities. The development of networks of relationships among people who lived and worked in some societies in Southern Africa enabled such communities to function effectively in facilitating improved WaSH practices [21].

Limitations
We reviewed articles from almost all the countries in Southern Africa but limited the search of articles to only those published in English thus possibly missing experiences from some countries in the region. We may also have missed some critical literature because we only focused on literature published in peer-reviewed journals. We acknowledge that the application of filters during database search may have excluded other studies that could have been relevant to the review. Despite these limitations, we believe that our search strategy was comprehensive, and that we reviewed relevant literature in public health and the subject matter we explored.

Conclusion
Water and sanitation are critical to ensuring healthy lifestyle. However, many people and communities in Southern Africa still lack access to safe water and improved sanitation facilities. Rural areas are the most affected by barriers to improved WaSH facilities compared to urban settings. Studies focusing on the mitigation of the existing inequalities related to WaSH developments should be conducted. Our review has shown that, the current WaSH conditions in Southern Africa do not equate to the improved WaSH standards described in the SDGs 6 on ensuring access to water and sanitation for all. Key barriers to improved WaSH practices identified include rurality, climate change, low investments to WaSH infrastructure, inadequate knowledge of water-borne illnesses and lack of community engagement. The review also identified facilitators to WaSH practices comprising social capital development, increased latrine ownership, effective local community engagement and increased investment to WaSH infrastructure. A knowledge gap exists in the continued monitoring of progress in facilitators and barriers to improved WaSH practices in the region. There is also a gap in the literature on solutions to mitigating existing barriers to improved WaSH practices in Southern Africa.